Basic Information
| Provider Information | |||||||||
| NPI: | 1417256637 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEWSOM | ||||||||
| FirstName: | TONYA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7675 WOLF RIVER CIR | ||||||||
| Address2: | CIRCLE SUITE#202 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381381750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017373021 | ||||||||
| FaxNumber: | 9015216405 | ||||||||
| Practice Location | |||||||||
| Address1: | 7675 WOLF RIVER CIR | ||||||||
| Address2: | SUITE#202 | ||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017373021 | ||||||||
| FaxNumber: | 9015216405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2011 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN0000015718 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1417256637 | 05 | MO | MEDICAID | 08031269 | 05 | MS | MEDICAID | APN0000015718 | 01 | TN | STATE LICENSE | OTHER | 1528835 | 05 | TN | MEDICAID | A810396 | 01 | MS | STATE LICENSE | OTHER |